The Countless Ripples of Health Care Reform

If there’s anything clear about health care reform, it’s that it’s unclear. Over the last 15 months, what has mostly been heard has been the two loudest sides, as political supporters and enemies of the health care policy changes under debate in Washington state their views frequently, at maximum volume. But the landmark reform legislation signed by President Obama in late March is expected to cause ripples in many worlds, both in the health care industry and beyond. The rules for doctors, patients, hospitals and medical schools will certainly change, but so too will the effects be felt in the financial sector, the 2010 elections and the technology industry. As such, the health care reform bill is kind of an amorphous entity, one that takes on totally different shapes depending on one’s professional perspective, political beliefs, and educational background.

Getting a read on all the ramifications of reform is an ambitious project, and the Health & America Briefing, organized by the Bloomberg news organization and the University of Chicago Medical Center on Tuesday, was suitably epic in its scope. Drawing upon dozens of experts from all corners of the country and all sectors of the economy, the event at the downtown Gleacher Center employed interviews and panel discussions to try to circumscribe the enormous changes the health care reforms are expected to cause. Some voiced optimism, some voiced concern, and the entire chorus only agreed on one thing: no one can predict the ultimate impact of what some called the most significant legislation of the last 50 years.

The most optimistic view was presented, logically, by one of the health care reform bill’s lead architects. Ezekiel Emanuel, special advisor on health policy in the Obama administration, led off the conference in a one-on-one chat with Bloomberg News’ Washington editor, Al Hunt, and called the bill “the most complex piece of social legislation America has ever tried.” Emanuel, while slightly less strident than his younger brother, White House Chief of Staff Rahm Emanuel, was still demonstrative in his defense of the bill, which he said would still cause sweeping improvements despite the necessary compromises it required to pass through a divided Congress.

Reaching beyond the insurance extensions that have gotten most of the ink, Emanuel pointed to several measures he thinks will dramatically restructure American medicine: an independent federal cost-control commission, improvements in health care technology, and added incentives for doctors to practice primary care. The hope, Emanuel said, is that the health care system can learn from small successes in improving care and bring those lessons to a wider population.

“You see pockets almost everywhere in the country with fantastic practices, and the issue…is scaling them,” Emanuel said. “I think that over the next five years may be our biggest project, is can we scale the good things that the health care system does: the efficient things, the high quality things.”

One place where Emanuel allowed a modicum of defeat was in the arena of end-of-life care: the massive expenditures accrued by medical interventions in terminal patients. While more than a quarter of Medicare dollars (and 10 percent of health care costs overall) are spent on end-of-life care, “no one is satisfied by it,” Emanuel said. Efforts to change how that process is handled by doctors and patients were demonized during the legislative debate as “death panels.”

“We have to do better,” Emanuel lamented. “It was a sad loss for the entire country.”

A subsequent panel – which included Eric Whitaker, director of the UCMC’s Urban Health Initiative – dialed in on the issue of end-of-life care. Moderated by Bloomberg’s Amanda Bennett, who documented the costs of her husband’s fatal battle with cancer in the BusinessWeek article “Lessons of a $618,616 Death,” the discussion was both personal and analytical. Eric Goren, the doctor at the University of Pennsylvania who recommended that Bennett’s husband be moved to hospice, said that in the absence of financial reforms, doctors need to learn to approach end-of-life situations and advise patients and their families in a much more personal way.

“You don’t ever really learn how to have those conversations; it’s not something you can teach in medical school,” Goren said. “You can’t teach a general approach that easily. A lot of it is the ability to listen to the person in front of you.”

Education was also the focus of a panel later in the day addressing how medical schools can meet an increased demand for primary care physicians. With 30 million more people receiving health insurance under the new bill, the need for more primary care doctors will be more urgent than ever, at a time when the number of medical students choosing the discipline has declined 12 out of the last 13 years. Mark Siegler, director of the MacLean Center for Clinical Medical Ethics at UCMC, led a panel of medical school administrators in discussing how best to encourage doctors to choose primary care, where career earnings are on average $3 million less than for sub-specialists.

“Of all the countries in the world, ours is the only one that lacks a foundation of a primary health care system as the grounding of the entire health system,” Siegler said. “That troubles me in many ways…can health reform succeed in improving access, improving quality, containing costs if the system is largely driven by sub-specialty care?”

While the health care reform bill carries incentives – including loan forgiveness and higher payments – to motivate doctors to choose primary care, medical schools still must do their part to encourage that choice in their students, the panelists agreed. Darrell Kirch, the president and CEO of the Association of American Medical Colleges, suggested the scandalous notion that standardized testing should play a smaller role in medical school admissions than other factors.

“Maybe undergraduate GPA and the MCAT are only one dimension of the doctor you want at the bedside,” Kirch said. “One of the things a lot of the admission communities are shifting toward is documenting deep service, especially in an underserved population…which might be a good indicator of who are the people who will really address the vulnerable populations of the future.”

Another theme woven through the day’s panels was the importance of information technology, IT, to the future of health care in America. Much of the reform bill’s cost-cutting measures depend upon improving efficiency in the health care system, part of which Emanuel argued would come from the implementation of electronic medical records in the country’s hospitals and clinics. But the final panel of the day, moderated by UCMC professor of radiology Paul Chang, added a shadow to that optimism. With two representatives from medical software companies alongside him, Chang vented his frustration with the current technology.

“Many of us believe we are ten years behind every other industry when it comes to our IT systems,” Chang said. “Not only do I have to deal with 4 or 5 systems, I have to have 5 different passwords, it’s incredibly frustrating. These systems require humans to be the integrating agent. I don’t have to do that when I’m using Amazon.”

But despite the diversity of expert opinions on display, the true verdict on health care reform will likely be determined by the masses, many of whom remain confused about what Obama’s bill actually contains. A panel of pollsters spoke about that confusion – many people approve of individual changes made by the bill, but remain opposed to overall “health care reform” – and how the reforms might become popular or resented in the future. According to Mark Blumenthal, the editor and publisher of Pollster.com, those opinions will largely be decided in the examination room.

“When Gallup asked Americans who they trust to make the right recommendation for health care reform, doctors led the list, not even close,” Blumenthal said. “Those conversations between patients and doctors will be where public opinion about this reform is made or broken over the next 2 or 3 years.”